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Pagoada-Torres JD, Villalobos-Díaz R, Pineda-Centeno LM, Pesci-Eguia L, Gomez-Villegas T, Rivera-Montes H, Portocarrero-Ortiz LA. Bilateral Sixth Nerve Palsy: A Rare Presentation of Primary Hypophysitis. Cureus 2024; 16:e58850. [PMID: 38784347 PMCID: PMC11115475 DOI: 10.7759/cureus.58850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2024] [Indexed: 05/25/2024] Open
Abstract
Cranial nerve palsy is common in pituitary disease and depends on the extension of the lesion into the cavernous sinuses. Bilateral cranial nerve palsy was described in pituitary adenomas with apoplexy and in only one case in hypophysitis. We present a case of a 32-year-old female manifesting with headache, diplopia, bilateral sixth nerve palsy, and hypopituitarism. Magnetic resonance imaging (MRI) revealed symmetric expansion of the pituitary gland, with bilateral cavernous sinus invasion and thickening of the pituitary stalk. Hypophysitis was suspected, and after treatment with IV methylprednisolone boluses, a decrease in the pituitary lesion was observed, with complete remission of sixth nerve palsy in the right eye and partial improvement in the left eye. In this case, we report an infrequent form of presentation of hypophysitis, and highlight that steroids are the first line of treatment.
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Affiliation(s)
- Josue D Pagoada-Torres
- Endocrinology, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez", Mexico City, MEX
| | - Rodolfo Villalobos-Díaz
- Neurosurgery, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez", Mexico City, MEX
| | - Luz M Pineda-Centeno
- Neurology, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez", Mexico City, MEX
| | - Luis Pesci-Eguia
- Ophthalmology, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez", Mexico City, MEX
| | - Thamar Gomez-Villegas
- Ophthalmology, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez", Mexico City, MEX
| | - Hector Rivera-Montes
- Endocrinology, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez", Mexico City, MEX
| | - Lesly A Portocarrero-Ortiz
- Neuroendocrinology, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez", Mexico City, MEX
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Salhi S, Oueslati I, Mouelhi Y, Zehani A, Kchir N, Kamoun E, Yazidi M, Chihaoui M. Secondary xanthogranulomatous hypophysitis mimicking a pituitary macroadenoma: a case report. J Int Med Res 2024; 52:3000605231223033. [PMID: 38190975 PMCID: PMC10775730 DOI: 10.1177/03000605231223033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 12/11/2023] [Indexed: 01/10/2024] Open
Abstract
Hypophysitis is an extremely rare inflammatory disease that can mimic the clinical and radiological features of a pituitary adenoma. In this case report, we describe a 45-year-old woman with secondary xanthogranulomatous hypophysitis (XGH) who presented with signs of a pituitary macroadenoma. The patient complained of headaches, visual impairment, and amenorrhea-galactorrhea syndrome. Her physical examination was normal. Laboratory investigation revealed corticotropin, thyrotropin, and gonadotropin deficiencies. She also had low visual acuity in her right eye and an altered visual field. Pituitary magnetic resonance imaging revealed an intra and suprasellar mass measuring 13 × 11 × 16 mm, with hemorrhagic necrosis, that was having a discrete mass effect on the patient's optic chiasm and pituitary stalk. The patient was treated with hydrocortisone and levothyroxine, and then transferred to the Neurosurgery department for total transsphenoidal resection of the mass. Histological examination of the tumor permitted a diagnosis of XGH of a remodeled Rathke's pouch cyst to be made. Systemic conditions such as tuberculosis, sarcoidosis, and other granulomatous diseases were excluded. The etiopathogenesis of XGH remains poorly characterized, but it may be a progressive form of lymphocytic hypophysitis or a remodeled Rathke's pouch cyst. Screening for autoimmune pathology and systemic diseases is essential to guide appropriate management.
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Affiliation(s)
- Salma Salhi
- Department of Endocrinology, La Rabta University Hospital, Faculty of Medicine, University of Tunis-El Manar, Tunis, Tunisia
| | - Ibtissem Oueslati
- Department of Endocrinology, La Rabta University Hospital, Faculty of Medicine, University of Tunis-El Manar, Tunis, Tunisia
| | - Yasmine Mouelhi
- Department of Endocrinology, La Rabta University Hospital, Faculty of Medicine, University of Tunis-El Manar, Tunis, Tunisia
| | - Alia Zehani
- Department of Pathology, La Rabta University Hospital, Faculty of Medicine, University of Tunis-El Manar, Tunis, Tunisia
| | - Nidhameddine Kchir
- Department of Pathology, La Rabta University Hospital, Faculty of Medicine, University of Tunis-El Manar, Tunis, Tunisia
| | - Elyes Kamoun
- Department of Endocrinology, La Rabta University Hospital, Faculty of Medicine, University of Tunis-El Manar, Tunis, Tunisia
| | - Meriem Yazidi
- Department of Endocrinology, La Rabta University Hospital, Faculty of Medicine, University of Tunis-El Manar, Tunis, Tunisia
| | - Melika Chihaoui
- Department of Endocrinology, La Rabta University Hospital, Faculty of Medicine, University of Tunis-El Manar, Tunis, Tunisia
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3
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Uccella S, Dottermusch M, Erickson L, Warmbier J, Montone K, Saeger W. Inflammatory and Infectious Disorders in Endocrine Pathology. Endocr Pathol 2023; 34:406-436. [PMID: 37209390 PMCID: PMC10199304 DOI: 10.1007/s12022-023-09771-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2023] [Indexed: 05/22/2023]
Abstract
A variety of inflammatory conditions may directly involve the endocrine glands, leading to endocrine dysfunction that can cause severe consequences on patients' health, if left untreated. Inflammation of the endocrine system may be caused by either infectious agents or other mechanisms, including autoimmune and other immune-mediated processes. Not infrequently, inflammatory and infectious diseases may appear as tumor-like lesions of endocrine organs and simulate neoplastic processes. These diseases may be clinically under-recognized and not infrequently the diagnosis is suggested on pathological samples. Thus, the pathologist should be aware of the basic principles of their pathogenesis, as well as of their morphological features, clinicopathological correlates, and differential diagnosis. Interestingly, several systemic inflammatory conditions show a peculiar tropism to the endocrine system as a whole. In turn, organ-specific inflammatory disorders are observed in endocrine glands. This review will focus on the morphological aspects and clinicopathological features of infectious diseases, autoimmune disorders, drug-induced inflammatory reactions, IgG4-related disease, and other inflammatory disorders involving the endocrine system. A mixed entity-based and organ-based approach will be used, with the aim to provide the practicing pathologist with a comprehensive and practical guide to the diagnosis of infectious and inflammatory disorders of the endocrine system.
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Affiliation(s)
- Silvia Uccella
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanule, Milan, Italy
- Pathology Service IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Matthias Dottermusch
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lori Erickson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN USA
| | - Julia Warmbier
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kathleen Montone
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA USA
| | - Wolfgang Saeger
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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4
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Kurokawa R, Kurokawa M, Baba A, Nakaya M, Kato S, Bapuraj J, Nakata Y, Ota Y, Srinivasan A, Abe O, Moritani T. Neuroimaging of hypophysitis: etiologies and imaging mimics. Jpn J Radiol 2023; 41:911-927. [PMID: 37010787 PMCID: PMC10468747 DOI: 10.1007/s11604-023-01417-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 03/24/2023] [Indexed: 04/04/2023]
Abstract
Hypophysitis is an inflammatory disease affecting the pituitary gland. Hypophysitis can be classified into multiple types depending on the mechanisms (primary or secondary), histology (lymphocytic, granulomatous, xanthomatous, plasmacytic/IgG4 related, necrotizing, or mixed), and anatomy (adenohypophysitis, infundibulo-neurohypophysitis, or panhypophysitis). An appropriate diagnosis is vital for managing these potentially life-threatening conditions. However, physiological morphological alterations, remnants, and neoplastic and non-neoplastic lesions may masquerade as hypophysitis, both clinically and radiologically. Neuroimaging, as well as imaging findings of other sites of the body, plays a pivotal role in diagnosis. In this article, we will review the types of hypophysitis and summarize clinical and imaging features of both hypophysitis and its mimickers.
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Affiliation(s)
- Ryo Kurokawa
- Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA.
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Mariko Kurokawa
- Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Akira Baba
- Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Moto Nakaya
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Shimpei Kato
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Jayapalli Bapuraj
- Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Yasuhiro Nakata
- Department Or Neuroradiology, Tokyo Metropolitan Neurological Hospital, 2-6-1 Musashidai, Fuchu, Tokyo, 183-0042, Japan
| | - Yoshiaki Ota
- Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Ashok Srinivasan
- Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Osamu Abe
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Toshio Moritani
- Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
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Menotti S, Giampietro A, Raia S, Veleno M, Angelini F, Tartaglione T, Gaudino S, Doglietto F, De Marinis L, Pontecorvi A, Bianchi A, Chiloiro S. Unveiling the Etiopathogenic Spectrum of Hypophysitis: A Narrative Review. J Pers Med 2023; 13:1210. [PMID: 37623461 PMCID: PMC10455260 DOI: 10.3390/jpm13081210] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 07/25/2023] [Accepted: 07/27/2023] [Indexed: 08/26/2023] Open
Abstract
Hypophysitis, a rare inflammatory disorder of the pituitary gland, has seen an uptick in reported cases in recent years. Our objective is to summarize the most recent research on the etiopathogenesis, molecular mechanisms, and genetics of both primary and secondary hypophysitis. Primary autoimmune hypophysitis (PAH): During the acute phase of the disease, the pituitary gland in enlarged due to the infiltration of T and B lymphocytes. The chronic phase is characterized by progressive and irreversible pituitary atrophy. APA may play a role in the management, diagnosis, and prognosis of PAH. Specific autoantibodies such as anti-GH, anti-PIT-1, and anti-T-PIT have been found in patients with hypophysitis and hypopituitarism. A recent study suggested that a mechanism of escaping clonal deletion and mounting an immune response against self antigens can explain the unusual nature of the immune response observed in PAH patients. A cytokine array shows the presence of gamma-interferon and interleukin-17. Patients carrying mutations in the PIT1 or PROP1 genes may present PAH. Individuals carrying the HLA DQ8 haplotype are four times more likely to develop PAH. Immune checkpoint inhibitors induce hypophysitis (IIHs): IIHs is an increasingly frequent toxicity of in patients on treatment with inhibitors targeting cytotoxic T-lymphocyte antigen 4 (CTLA-4) and programmed cell death-1 (PD-1). ICIs inhibit the CTLA-4 pathway, leading to overactivation of T lymphocytes. The binding of PD-1/PD-L1 suppresses the activity of T cells, promotes the conversion of T-helpers into T-regulatory cells, and activates pro-survival signaling pathways in cancer cells. Cytokines play a crucial role in IIHs. B-cell infiltration has been observed in IIHs, suggesting that antibody-mediated pituitary injury may contribute. Genetic polymorphisms of CTLA-4 and PD-1 genes can increase the risk of IIHs. HLA alleles may also be involved in the onset of IIHs; this HLA association presents a possible alternative mechanistic hypothesis. IIHs may also be linked to a paraneoplastic syndrome triggered by ectopic expression of pituitary specific antigens. SARS-CoV-2-related hypophysitis: Recently, the literature has reported occurrences of hypophysitis associated with the SARS-CoV-2 virus; long COVID-19 may also present as infundibulo-neuro-hypophysitis. The virus enters the central nervous system because of its distinct interaction with angiotensin-converting enzyme receptors via spike proteins binding the capillary endothelium, and it directly damages the pituitary cells. The effect of SARS-CoV-2 can occur indirectly through inflammation and the release of cytokines. The exact mechanism remains ambiguous. The available data on endocrine complications associated with the SARS-CoV-2 vaccine are scant. Nonetheless, isolated cases of hypophysitis have been documented. Treatment of hypophysitis: Glucocorticoids are the cornerstone in managing primary hypophysitis, given their targeted action on inflammation. A better understanding of the etiopathogenesis and molecular mechanism of hypophysitis can lead to more effective and personalized treatment strategies.
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Affiliation(s)
- Sara Menotti
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (S.M.); (A.G.); (S.R.); (M.V.); (F.A.); (L.D.M.); (A.P.); (S.C.)
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (T.T.); (S.G.); (F.D.)
| | - Antonella Giampietro
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (S.M.); (A.G.); (S.R.); (M.V.); (F.A.); (L.D.M.); (A.P.); (S.C.)
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (T.T.); (S.G.); (F.D.)
| | - Salvatore Raia
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (S.M.); (A.G.); (S.R.); (M.V.); (F.A.); (L.D.M.); (A.P.); (S.C.)
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (T.T.); (S.G.); (F.D.)
| | - Miriam Veleno
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (S.M.); (A.G.); (S.R.); (M.V.); (F.A.); (L.D.M.); (A.P.); (S.C.)
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (T.T.); (S.G.); (F.D.)
| | - Flavia Angelini
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (S.M.); (A.G.); (S.R.); (M.V.); (F.A.); (L.D.M.); (A.P.); (S.C.)
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (T.T.); (S.G.); (F.D.)
| | - Tommaso Tartaglione
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (T.T.); (S.G.); (F.D.)
- Department of Radiodiagnostic, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Simona Gaudino
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (T.T.); (S.G.); (F.D.)
- Department of Radiodiagnostic, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Francesco Doglietto
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (T.T.); (S.G.); (F.D.)
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Laura De Marinis
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (S.M.); (A.G.); (S.R.); (M.V.); (F.A.); (L.D.M.); (A.P.); (S.C.)
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (T.T.); (S.G.); (F.D.)
| | - Alfredo Pontecorvi
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (S.M.); (A.G.); (S.R.); (M.V.); (F.A.); (L.D.M.); (A.P.); (S.C.)
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (T.T.); (S.G.); (F.D.)
| | - Antonio Bianchi
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (S.M.); (A.G.); (S.R.); (M.V.); (F.A.); (L.D.M.); (A.P.); (S.C.)
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (T.T.); (S.G.); (F.D.)
| | - Sabrina Chiloiro
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (S.M.); (A.G.); (S.R.); (M.V.); (F.A.); (L.D.M.); (A.P.); (S.C.)
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (T.T.); (S.G.); (F.D.)
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Patra S, Trivedi P. A unique coexistence of a plurihormonal pituitary adenoma with granulomatous hypophysitis. INDIAN J PATHOL MICR 2023; 66:618-620. [PMID: 37530354 DOI: 10.4103/ijpm.ijpm_439_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023] Open
Abstract
Dual pathology in the pituitary gland is a unique phenomenon. Coexistence of a pituitary adenoma with primary hypophysitis has been reported rarely with very few cases in the literature. Among the primary hypophysitis, primary granulomatous subtype has been proposed to be idiopathic and autoimmune in nature. Plurihormonal pituitary adenomas produce hormones of more than one different pituitary cell lineage. Pituitary adenoma with a single hormonal content has been documented with concurrent primary granulomatous hypophysitis. The present case describes the unique coexistence of a plurihormonal adenoma showing somatotroph, lactotroph, and corticotroph lineage with primary granulomatous inflammation in the sellar region in a 36-year-old woman.
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Affiliation(s)
- Sanjiban Patra
- Department of Oncopathology, The Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India
| | - Priti Trivedi
- Department of Oncopathology, The Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India
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Naser PV, Papadopoulou P, Teuber J, Kopf S, Jesser J, Unterberg AW, Beynon C. Characteristics of inflammatory and infectious diseases of the pituitary gland in patients undergoing transsphenoidal surgery. Pituitary 2023:10.1007/s11102-023-01333-4. [PMID: 37389775 PMCID: PMC10397134 DOI: 10.1007/s11102-023-01333-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/15/2023] [Indexed: 07/01/2023]
Abstract
PURPOSE Inflammatory and infectious diseases of the pituitary gland (IIPD) are rare lesions often misdiagnosed preoperatively. Immediate surgery is indicated especially in cases of neurological impairment. However, (chronic) inflammatory processes can mimic other pituitary tumors, such as adenomas, and data on the preoperative diagnostic criteria for IIPD are sparse. METHODS We retrospectively reviewed medical records of 1317 patients who underwent transsphenoidal surgery at our institution between March 2003 and January 2023. A total of 26 cases of histologically confirmed IIPD were identified. Patient records, laboratory parameters, and postoperative course were analyzed and compared with an age, sex, and tumor volume-matched control group of nonfunctioning pituitary adenomas. RESULTS Pathology confirmed septic infection in ten cases, most commonly caused by bacteria (3/10) and fungi (2/10). In the aseptic group, lymphocytic hypophysitis (8/26) and granulomatous inflammation (3/26) were most frequently observed. Patients with IIPD commonly presented with endocrine and/or neurological dysfunction. No surgical mortality occurred. Preoperative radiographic findings (cystic/solid tumor mass, contrast enhancement) did not significantly differ between IIPD and adenomas. At follow-up, 13 patients required permanent hormone substitution. CONCLUSION In conclusion, correct preoperative diagnosis of IIPD remains challenging, as neither radiographic findings nor preoperative laboratory workup unequivocally identify these lesions. Surgical treatment facilitates decompression of supra- and parasellar structures. Furthermore, this low-morbidity procedure enables the identification of pathogens or inflammatory diseases requiring targeted medical treatment, which is crucial for these patients. Establishing a correct diagnosis through surgery and histopathological confirmation thus remains of utmost importance.
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Affiliation(s)
- Paul Vincent Naser
- Department of Neurosurgery, Heidelberg University, Im Neuenheimer Feld 400, Heidelberg, 69120, Germany.
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, Heidelberg, 69120, Germany.
| | - Penelope Papadopoulou
- Department of Neurosurgery, Heidelberg University, Im Neuenheimer Feld 400, Heidelberg, 69120, Germany
| | - Jan Teuber
- Department of Neurosurgery, Heidelberg University, Im Neuenheimer Feld 400, Heidelberg, 69120, Germany
| | - Stefan Kopf
- Department of Endocrinology, Heidelberg University, Im Neuenheimer Feld 410, Heidelberg, 69120, Germany
| | - Jessica Jesser
- Department of Neuroradiology, Heidelberg University, Im Neuenheimer Feld 400, Heidelberg, 69120, Germany
| | - Andreas W Unterberg
- Department of Neurosurgery, Heidelberg University, Im Neuenheimer Feld 400, Heidelberg, 69120, Germany
| | - Christopher Beynon
- Department of Neurosurgery, Heidelberg University, Im Neuenheimer Feld 400, Heidelberg, 69120, Germany
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8
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Ach T, Ben Yahia W, Halloul I, Sghaier F, Atig A. Neurosarcoidosis-Induced Hypophysitis Mimicking Pituitary Macroadenoma. Cureus 2023; 15:e39865. [PMID: 37404438 PMCID: PMC10315063 DOI: 10.7759/cureus.39865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2023] [Indexed: 07/06/2023] Open
Abstract
Sarcoidosis is characterized by the presence of noncaseating granulomatous inflammation in the affected organs. Isolated involvement of the hypothalamic-pituitary axis in patients with sarcoidosis is rare. We report a rare case of a female patient in whom hypophysitis, mimicking a pituitary macroadenoma, resulted in pituitary transsphenoidal surgery. A female patient had been complaining of bilateral temporal headaches for over a month. Brain MRI showed a pituitary adenoma of height 16 mm, width 16 mm, and depth 12 mm. Hormonal assay showed central hypothyroidism and elevated level of prolactin. Histological examination revealed granulomatous hypophysitis. A specific search for Mycobacterium tuberculosis was negative on the pituitary tissue. After the exclusion of differential diagnoses, the combination of clinical, laboratory and radiological tests led to the diagnosis of neurosarcoidosis. This report presents an uncommon case of a pituitary localization of neurosarcoidosis mimicking a macroadenoma. Understanding the different MRI aspects of neurosarcoidosis is essential to avoid interpretive blunders that could result in an incorrect diagnosis.
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Affiliation(s)
- Taïeb Ach
- Endocrinology, University Hospital of Farhat Hached, Sousse, TUN
| | - Wissal Ben Yahia
- Internal Medicine, University Hospital of Farhat Hached, Sousse, TUN
| | - Imen Halloul
- Endocrinology, University Hospital of Farhat Hached, Sousse, TUN
| | - Fatma Sghaier
- Internal Medicine, University Hospital of Farhat Hached, Sousse, TUN
| | - Amira Atig
- Internal Medicine, University Hospital of Farhat Hached, Sousse, TUN
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9
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Tripuraneni SC, Dharmapuri S, Gera S, Boyapati M. Granulomatous Hypophysitis - A Case Report. Indian J Otolaryngol Head Neck Surg 2023; 75:1233-1237. [PMID: 37275024 PMCID: PMC10235352 DOI: 10.1007/s12070-023-03500-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 01/16/2023] [Indexed: 02/05/2023] Open
Abstract
Hypophysitis is a rare pituitary condition that commonly presents with nonspecific clinical and radiological patterns and is commonly misdiagnosed as pituitary adenoma. Definitive diagnosis can be made only by histopathology. No clearcut guidelines have been established for its management. This is a case report of one of such rare case.
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Affiliation(s)
- Satish chandra Tripuraneni
- Department of otorhinolaryngology & Head and neck surgery, Dr Pinnamaneni Siddhartha institute of medical sciences & Research foundation, Vijayawada, India
- Department of neurosciences & Pathology Andhra hospitals, Vijayawada, India
- Flat no 501 Saikarteek residency Main road, currancynagar, 520008 Vijayawada, Andharapradesh, India
| | - Sivakumar Dharmapuri
- Department of otorhinolaryngology & Head and neck surgery, Dr Pinnamaneni Siddhartha institute of medical sciences & Research foundation, Vijayawada, India
- Department of neurosciences & Pathology Andhra hospitals, Vijayawada, India
| | - Sameera Gera
- Department of otorhinolaryngology & Head and neck surgery, Dr Pinnamaneni Siddhartha institute of medical sciences & Research foundation, Vijayawada, India
- Department of neurosciences & Pathology Andhra hospitals, Vijayawada, India
| | - Mallika Boyapati
- Department of otorhinolaryngology & Head and neck surgery, Dr Pinnamaneni Siddhartha institute of medical sciences & Research foundation, Vijayawada, India
- Department of neurosciences & Pathology Andhra hospitals, Vijayawada, India
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Rabiei MM, Ebrahimzadeh K, Davoudi Z, Bidari Zerehpoosh F, Javandoust Gharehbagh F, Sedaghati R, Lotfollahi L, Kalhor F, Alavi Darazam I. A case of pituitary gland abscess associated with granulomatous hypophysitis. BMC Neurol 2023; 23:11. [PMID: 36631799 PMCID: PMC9835326 DOI: 10.1186/s12883-023-03060-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 12/24/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Granulomatous hypophysitis is a rare disease that presents with chronic inflammation of the pituitary gland. In this study, we reported a case of granulomatous hypophysitis associated with a pituitary abscess. CASE PRESENTATION A 39-year-old woman presented with a 2-year history of infertility. For the past six months, she has suffered from amenorrhea, decreased libido, headaches, and vertigo. She was referred to our hospital with a suspected diagnosis of nonfunctioning pituitary adenoma based on her presentation and brain MRI findings. She underwent trans-sphenoidal surgery (TSS). Direct observation during surgery revealed drainage of malodor pus and pituitary gland abscess. The histopathological evaluation also showed granulomatous hypophysitis and neutrophilic microabscess formation. The patient was initially treated with high doses of ceftriaxone (2 g twice daily) and metronidazole (500 mg (mg) four times per day). Also, the patient received cortisol replacement therapy after the operation. After obtaining the antibiogram and culture results, the treatment regimen was continued for 4 weeks postoperatively, followed by amoxicillin-clavulanate (500/125 mg three times daily) for a total duration of 12 weeks. CONCLUSION The patient recovered uneventfully and the postoperative MRI was normal without any remnant lesions.
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Affiliation(s)
- Mohammad Mahdi Rabiei
- grid.411600.2Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Kaveh Ebrahimzadeh
- grid.411600.2Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zahra Davoudi
- grid.411600.2Department of Endocrinology, Skull Base Research Center of Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farahnaz Bidari Zerehpoosh
- grid.411600.2Department of Pathology, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farid Javandoust Gharehbagh
- grid.411600.2Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Roghayeh Sedaghati
- grid.411600.2Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Legha Lotfollahi
- grid.411600.2Department of Nephrology, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fatemeh Kalhor
- grid.411600.2Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ilad Alavi Darazam
- grid.411600.2Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran ,grid.411600.2Department of Infectious Diseases and Tropical Medicine, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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11
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Touraine P, Sagna Y, Mattsson AF, Burman P, Van Beek AP, Carlsson MO, Aydin F, Feldt-Rasmussen U, Camacho-Hübner C. Pituitary function and the response to GH therapy in patients with Langerhans cell histiocytosis: analysis of the KIMS database. Eur J Endocrinol 2022; 187:373-381. [PMID: 35830276 PMCID: PMC9346264 DOI: 10.1530/eje-22-0160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 07/04/2022] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To analyze the effectiveness and safety of growth hormone (GH) replacement treatment in adult patients with Langerhans cell histiocytosis (LCH) and GH deficiency (GHD) enrolled in KIMS (Pfizer International Metabolic Database). PATIENTS AND METHODS Patients with LCH and GHD were studied at baseline and some of them after 1 year of GH treatment. The effectiveness of GH is presented as change after 1 year of treatment (mean, 95% CI). The LCH population was compared to two other groups of patients enrolled in KIMS, granulomatous and lymphocytic hypophysitis. RESULTS At baseline, 81 adults with LCH (27 with childhood onset, 56% females), mean age at GHD onset of 29 (15) years were studied. Diabetes insipidus was diagnosed in 86% of patients. Analysis of 1 year of GH treatment was possible in 37 patients. One-year cross-sectional values for the GH dose were 0.39 (s.d.± 0.21) mg and -0.5 (-1.2 to 0.2) for insulin-like growth factor-1 s.d. Total cholesterol decreased 0.9 (-1.5 to -0.3 (mmol/L); P < 0.05); AGHDA-QoL-score (n = 20) was improved by 2.8 points (-5.6 to 0.0; P < 0.05), while mean BMI increased 0.6 ± 3 kg/m2 (95% CI: -0.2 to 1.4). All these effects did not differ from the two other groups after adjusting for age, gender, and baseline values. In 20 of 77 patients included in the safety analysis, 36 serious adverse events were reported during 435 patient-years (82.8/1000); no new safety signals were reported. CONCLUSION After 1 year of GH treatment in patients with LCH, metabolic variables and quality of life improved, with no new safety signals.
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Affiliation(s)
- Philippe Touraine
- Department of Endocrinology and Reproductive Medicine, Centre de Maladies Endocriniennes Rares de la Croissance et du Développement, Hôpital Universitaire Pitié Salpêtrière-Charles Foix, Sorbonne Université, Faculté de médecine, Paris Cedex 13, France
- Correspondence should be addressed to P Touraine;
| | - Yempabou Sagna
- Department of Internal Medicine, CHU Souro Sanou, Intitut Supérieur des Sciences de la Santé (IN.S.SA), Université Nazi Boni, Bobo-Dioulasso, Burkina Faso
| | | | - Pia Burman
- Department of Endocrinology, Skåne University Hospital, University of Lund, Malmö, Sweden
| | - André P Van Beek
- Department of Endocrinology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | | | | | - Ulla Feldt-Rasmussen
- Department of Endocrinology and Metabolism, Rigshospitalet, and Institute of Clinical Sciences, Copenhagen University, Copenhagen, Denmark
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12
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Mark IT, Glastonbury CM. Diffuse Basisphenoid Enhancement: Possible Differentiating Feature for Granulomatous Hypophysitis. AJNR Am J Neuroradiol 2022; 43:1341-1345. [PMID: 36007945 PMCID: PMC9451629 DOI: 10.3174/ajnr.a7618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 06/28/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE Granulomatous hypophysitis is a rare inflammatory condition of the pituitary gland with an imaging appearance that can overlap with that of pituitary adenoma. Differentiating the two before surgical resection can have important treatment implications. The purpose of our study was to determine whether it was possible to differentiate between granulomatous hypophysitis and pituitary adenoma on the basis of diffuse enhancing infrasellar basisphenoid bone marrow. MATERIALS AND METHODS We present 3 cases, initially thought to be pituitary adenomas, that were pathology-proved granulomatous hypophysitis. The preoperative MR images were reviewed for diffuse, enhancing infrasellar basisphenoid bone marrow. For comparison, we reviewed 100 cases of pathology-proved pituitary adenoma for the same finding. Additionally, imaging findings including the sphenoid sinus pneumatization pattern, clinical history, laboratory values, and pathology results were reviewed. RESULTS All 3 cases of granulomatous hypophysitis had diffuse enhancing infrasellar basisphenoid bone marrow. Conversely, this was not seen in any of the 100 pituitary adenomas. The patients with granulomatous hypophysitis were all women. Two patients had idiopathic granulomatous hypophysitis, and 1 had secondary granulomatous hypophysitis with sarcoidosis. Of the 100 patients with pituitary adenomas, 67 were women. The basisphenoid pneumatization patterns was as follows: 15 (type 2), 40 (type 3), and 45 (type 4). CONCLUSIONS We present 3 cases of granulomatous hypophysitis with diffuse enhancement of the infrasellar basisphenoid bone marrow that was not seen in our 100 cases of pituitary adenomas. This imaging feature may be valuable for suggesting a diagnosis of granulomatous hypophysitis and avoiding surgical resection of what might otherwise be misdiagnosed as a pituitary adenoma.
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Affiliation(s)
- I T Mark
- From the Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - C M Glastonbury
- From the Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
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13
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Kiran MM, Bal E, Kuratmer AD, Ercan K, Gumuskaya B, Erdogan F. Idiopathic granulomatous hypophysitis mimicking adenoma. REVISTA ESPANOLA DE PATOLOGIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ANATOMIA PATOLOGICA Y DE LA SOCIEDAD ESPANOLA DE CITOLOGIA 2022; 55:203-206. [PMID: 35779888 DOI: 10.1016/j.patol.2019.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 11/06/2019] [Accepted: 11/20/2019] [Indexed: 06/15/2023]
Abstract
Hypophysitis is a rare disease of pituitary gland, which, although it is usually a primary lesion, can also occur secondary to systemic conditions. Granulomatous hypophysitis is an inflammatory disease condition which accounts for less than 1% of all cellular lesions and can mimic adenoma. A 32-year-old woman presented with weight gain, galactorrhea and blurred vision. The MRI showed a cystic, nodular lesion in the intermediate lobe of the pituitary gland and the initial diagnosis was adenoma. She underwent surgery and the histopathology revealed granulomas composed of epithelioid histiocytes, multinuclear giant cells and mononuclear inflammatory cells. Inflammatory diseases of the pituitary gland are much less frequent than pituitary adenomas and idiopathic granulomatous hypophysitis is extremely rare. Histopathology and the ruling out of a systemic cause are the gold standards for its diagnosis.
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Affiliation(s)
| | - Ercan Bal
- Department of Neurosurgery, Ankara Yildirim Beyazit University, Ankara, Turkey
| | - Ayca Dilsad Kuratmer
- Department of Pathology, Ankara Bilkent State Hospital, Ankara, Turkey; Department of Pathology, Ankara Yildirim Beyazit University, Ankara, Turkey
| | - Karabekir Ercan
- Department of Radiology, Ankara Bilkent State Hospital, Ankara, Turkey
| | - Berrak Gumuskaya
- Department of Pathology, Ankara Bilkent State Hospital, Ankara, Turkey; Department of Pathology, Ankara Yildirim Beyazit University, Ankara, Turkey
| | - Fazli Erdogan
- Department of Pathology, Ankara Bilkent State Hospital, Ankara, Turkey; Department of Pathology, Ankara Yildirim Beyazit University, Ankara, Turkey
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14
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Abstract
OBJECTIVE Hypophysitis is considered a rare inflammatory disease of the pituitary gland. For a long time, primary autoimmune hypophysitis has stood out as the most relevant type of hypophysitis. However, with the advent of immunotherapy for the treatment of malignancies and identification of hypophysitis as an immune-related adverse event, hypophysitis has garnered increasing interest and recognition. Therefore, awareness, early recognition, and appropriate management are becoming important as the indication for immunomodulatory therapies broaden. METHODS In this review, we discuss the epidemiology, diagnosis, and treatment of hypophysitis with a focus on recent data and highlight subtypes of particular interest while recognizing the gaps in knowledge that remain. RESULTS Regardless of cause, symptoms and signs of hypophysitis may be related to mass effect (headache and visual disturbance) and hormonal disruption that warrant prompt evaluation. In the vast majority of cases, a diagnosis of hypophysitis can be made presumptively in the appropriate clinical context with radiologic findings consistent with hypophysitis and after the exclusion of other causes. CONCLUSION Although subtle differences currently exist in management and outcome expectations between primary and secondary causes of hypophysitis, universally, treatment is aimed at symptom management and hormonal replacement therapy.
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15
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Langlois F, Varlamov EV, Fleseriu M. Hypophysitis, the Growing Spectrum of a Rare Pituitary Disease. J Clin Endocrinol Metab 2022; 107:10-28. [PMID: 34528683 PMCID: PMC8684465 DOI: 10.1210/clinem/dgab672] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Indexed: 01/13/2023]
Abstract
Hypophysitis is defined as inflammation of the pituitary gland that is primary or secondary to a local or systemic process. Differential diagnosis is broad (including primary tumors, metastases, and lympho-proliferative diseases) and multifaceted. Patients with hypophysitis typically present with headaches, some degree of anterior and/or posterior pituitary dysfunction, and enlargement of pituitary gland and/or stalk, as determined by imaging. Most hypophysitis causes are autoimmune, but other etiologies include inflammation secondary to sellar tumors or cysts, systemic diseases, and infection or drug-induced causes. Novel pathologies such as immunoglobulin G4-related hypophysitis, immunotherapy-induced hypophysitis, and paraneoplastic pituitary-directed autoimmunity are also included in a growing spectrum of this rare pituitary disease. Typical magnetic resonance imaging reveals stalk thickening and homogenous enlargement of the pituitary gland; however, imaging is not always specific. Diagnosis can be challenging, and ultimately, only a pituitary biopsy can confirm hypophysitis type and rule out other etiologies. A presumptive diagnosis can be made often without biopsy. Detailed history and clinical examination are essential, notably for signs of underlying etiology with systemic manifestations. Hormone replacement and, in selected cases, careful observation is advised with imaging follow-up. High-dose glucocorticoids are initiated mainly to help reduce mass effect. A response may be observed in all auto-immune etiologies, as well as in lymphoproliferative diseases, and, as such, should not be used for differential diagnosis. Surgery may be necessary in some cases to relieve mass effect and allow a definite diagnosis. Immunosuppressive therapy and radiation are sometimes also necessary in resistant cases.
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Affiliation(s)
- Fabienne Langlois
- Department of Medicine, Division of Endocrinology, Centre intégré universitaire de santé et de services sociaux de l’Estrie - Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Elena V Varlamov
- Departments of Medicine (Division of Endocrinology, Diabetes and Clinical Nutrition) and Neurological Surgery, and Pituitary Center, Oregon Health & Science University, Portland, Oregon, USA
| | - Maria Fleseriu
- Departments of Medicine (Division of Endocrinology, Diabetes and Clinical Nutrition) and Neurological Surgery, and Pituitary Center, Oregon Health & Science University, Portland, Oregon, USA
- Correspondence: Maria Fleseriu, MD, Oregon Health & Science University, Mail Code CH8N, 3303 S Bond Ave, Portland, Oregon 97239, USA.
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16
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de Vries F, van Furth WR, Biermasz NR, Pereira AM. Hypophysitis: A comprehensive overview. Presse Med 2021; 50:104076. [PMID: 34687912 DOI: 10.1016/j.lpm.2021.104076] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/27/2021] [Accepted: 10/12/2021] [Indexed: 10/20/2022] Open
Abstract
Hypophysitis is defined as inflammation of the pituitary gland. It is a heterogeneous condition as it can originate from different parts of the pituitary gland, can be caused by different pathophysiological processes, and can be isolated or the manifestation of a underlying systemic disease. Hypophysitis usually presents with endocrine deficiencies, including diabetes insipidus, with varying patterns. A subset of patients presents with mass effects. The last decades major progress has been made in the understanding of this disease. New forms are now recognized, new diagnostics are being developed, and specific treatments are proposed. This review provides an overview of the current knowledge on hypophysitis using an aetiology-based approach and provides the clinician with a stepwise approach to the patient with (suspected) hypophysitis.
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Affiliation(s)
- F de Vries
- Department of Neurosurgery and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands; Department of Medicine, Division of Endocrinology and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands
| | - W R van Furth
- Department of Neurosurgery and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands
| | - N R Biermasz
- Department of Medicine, Division of Endocrinology and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands
| | - A M Pereira
- Department of Medicine, Division of Endocrinology and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands
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17
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Murvelashvili N, Tessnow A. A Case of Hypophysitis Following Immunization With the mRNA-1273 SARS-CoV-2 Vaccine. J Investig Med High Impact Case Rep 2021; 9:23247096211043386. [PMID: 34553641 PMCID: PMC8474296 DOI: 10.1177/23247096211043386] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
The emergence of a novel coronavirus and global pandemic raised the need for the rapid development of new vaccines to reduce the morbidity and mortality associated with Covid-19. Common side effects of these vaccines such as myalgia, arthralgia, nausea, fatigue, and injection site reaction are usually self-resolving. Recognition of other potential adverse effects of these novel vaccines is important due to their rapid and widespread distribution. We report a case of a 51-year-old man admitted to Parkland Memorial Hospital with headache, nausea, vomiting, malaise, and diffuse arthralgias 3 days after he received his second mRNA-1273 SARS-CoV-2 vaccination. He was found to have hyponatremia and a low serum cortisol level. Further workup revealed hypopituitarism with central hypothyroidism, hypogonadism, and a subnormal response to cosyntropin. Magnetic resonance imaging revealed a diffusely enlarged pituitary gland consistent with acute hypophysitis. The patient responded well to glucocorticoid and thyroid hormone supplementation and was discharged after 2 days in the hospital. This is the first reported case of hypopituitarism potentially associated with Covid-19 immunization.
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Affiliation(s)
| | - Alex Tessnow
- The University of Texas Southwestern Medical Center, Dallas, USA
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18
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Frasca F, Piticchio T, Le Moli R, Malaguarnera R, Campennì A, Cannavò S, Ruggeri RM. Recent insights into the pathogenesis of autoimmune hypophysitis. Expert Rev Clin Immunol 2021; 17:1175-1185. [PMID: 34464545 DOI: 10.1080/1744666x.2021.1974297] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Hypophysitis is an inflammation of the pituitary gland and a rare case of hypopituitarism. Despite the expanding spectrum of histological variants and causative agents, its pathogenesis is far to be fully understood. The present review is focused on recent evidence concerning the pathogenesis of autoimmune hypophysitis by searching through online databases like MEDLINE and Scopus up to May 2021. AREAS COVERED Hypophysitis frequently develops in the context of a strong autoimmune background, including a wide spectrum of subtypes ranging from the commonest form of lymphocytic hypophysitis to the newly described and less common IgG4-, anti-PIT-1, and ICI-induced forms. A peculiar combination of genetic predisposition, pituitary damage and immunological setting represents the pathogenetic basis of autoimmune hypophysitis, which is characterized by diffuse infiltration of the gland by lymphocytes and variable degrees of fibrosis followed by pituitary cell destruction. Anti-pituitary antibodies (APA) have been described in sera from patients suffering from autoimmune hypophysitis, though their pathophysiological significance remains largely unknown and their diagnostic value limited. EXPERT OPINION In recent years hypophysitis has gained interest due to the increased number of new diagnoses and the recognition of novel subtypes. Further studies could lead to improvements in biochemical/immunological diagnosis and targeted treatments.
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Affiliation(s)
- Francesco Frasca
- Endocrinology Section, Department of Clinical and Experimental Medicine, Garibaldi Nesima Hospital, University of Catania, Catania, Italy
| | - Tommaso Piticchio
- Endocrinology Section, Department of Clinical and Experimental Medicine, Garibaldi Nesima Hospital, University of Catania, Catania, Italy
| | - Rosario Le Moli
- Endocrinology Section, Department of Clinical and Experimental Medicine, Garibaldi Nesima Hospital, University of Catania, Catania, Italy
| | | | - Alfredo Campennì
- Unit of Nuclear Medicine, Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, University of Messina, Messina, Italy
| | - Salvatore Cannavò
- Unit of Endocrinology, University Hospital of Messina, Messina, Italy.,Department of Human Pathology DETEV, University of Messina, Messina, Italy
| | - Rosaria Maddalena Ruggeri
- Unit of Endocrinology, University Hospital of Messina, Messina, Italy.,Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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Karrou M, Benyakhlef S, Alla A, Messaoudi N, Amar AO, Rouf S, Kamaoui I, Oulali N, Moufid F, Abda N, Latrech H. Clinical presentation and management of hypophysitis: An observational study of case series. Surg Neurol Int 2021; 12:304. [PMID: 34345445 PMCID: PMC8326108 DOI: 10.25259/sni_454_2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 05/24/2021] [Indexed: 01/13/2023] Open
Abstract
Background: Hypophysitis is described as a rare chronic inflammatory affection of the pituitary gland. However, to date, its pathogenesis has not been completely cleared up. Clinical features are polymorphic, including symptoms related to inflammatory compression and/or hypopituitarism. Laboratory tests determine hormone deficiencies orientating replacement therapy’s protocol. MRI of the hypothalamic-pituitary region is crucial in exhibiting major radiological signs such as pituitary homogeneous enlargement and gland stalk’s thickening. The etiological diagnosis is still challenging without affecting the management strategy. Corticosteroids have widely been used but a close follow-up without any treatment has also been approved. Case Description: In this report, seven patients with hypophysitis have been collected over a period of 6 years. The average age of our patients was 32.1 years ± 11.8 with a female predominance (71.4%). Panhypopituitarism was objective in 42.9% of cases, a combined deficiency of the hypothalamic-pituitary thyroid, adrenal and gonadal axes in 28.6% of cases. A central diabetes insipidus was noted in 42.9% of the patients. Idiopathic hypophysitis was the most common etiology. The use of long course corticosteroids was required in 28.6% when compressive signs were reported. Conclusion: Hypophysitis remains a rare disease with nonspecific clinical and radiological patterns. Autoimmune origin seems to be the most frequent etiology. No guidelines have been established for hypophysitis management and the evolution is still unpredictable.
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Affiliation(s)
- Marouan Karrou
- Department of Endocrinology-Diabetology and Nutrition, Medical School, Mohammed VI University Hospital Centre, Oujda, Oujda-Angad, Morocco
| | - Salma Benyakhlef
- Department of Endocrinology-Diabetology and Nutrition, Medical School, Mohammed VI University Hospital Centre, Oujda, Oujda-Angad, Morocco
| | - Achwak Alla
- Department of Endocrinology-Diabetology and Nutrition, Medical School, Mohammed VI University Hospital Centre, Oujda, Oujda-Angad, Morocco
| | - Najoua Messaoudi
- Department of Endocrinology-Diabetology and Nutrition, Medical School, Mohammed VI University Hospital Centre, Oujda, Oujda-Angad, Morocco
| | - Asmae Oulad Amar
- Department of Radiology, Medical School, Mohammed VI University Hospital Centre, Oujda, Oujda-Angad, Morocco
| | - Siham Rouf
- Department of Endocrinology-Diabetology and Nutrition, Medical School, Mohammed VI University Hospital Centre, Oujda, Oujda-Angad, Morocco
| | - Imane Kamaoui
- Department of Radiology, Medical School, Mohammed VI University Hospital Centre, Oujda, Oujda-Angad, Morocco
| | - Noureddine Oulali
- Department of Neurosurgery Medical School, Mohammed VI University Hospital Centre, Oujda, Oujda-Angad, Morocco
| | - Faycal Moufid
- Department of Neurosurgery Medical School, Mohammed VI University Hospital Centre, Oujda, Oujda-Angad, Morocco
| | - Naima Abda
- Department of Epidemiology, Medical School, Mohammed VI University Hospital Centre, Oujda, Oujda-Angad, Morocco
| | - Hanane Latrech
- Department of Endocrinology-Diabetology and Nutrition, Medical School, Mohammed VI University Hospital Centre, Oujda, Oujda-Angad, Morocco
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20
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Nguyen H, Shah K, Waguespack SG, Hu MI, Habra MA, Cabanillas ME, Busaidy NL, Bassett R, Zhou S, Iyer PC, Simmons G, Kaya D, Pitteloud M, Subudhi SK, Diab A, Dadu R. Immune checkpoint inhibitor related hypophysitis: diagnostic criteria and recovery patterns. Endocr Relat Cancer 2021; 28:419-431. [PMID: 33890870 PMCID: PMC8183642 DOI: 10.1530/erc-20-0513] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 04/23/2021] [Indexed: 01/11/2023]
Abstract
Data on the diagnosis, natural course and management of immune checkpoint inhibitor (ICI)-related hypophysitis (irH) are limited. We propose this study to validate the diagnostic criteria, describe characteristics and hormonal recovery and investigate factors associated with the occurrence and recovery of irH. A retrospective study including patients with suspected irH at the University of Texas MD Anderson Cancer Center from 5/2003 to 8/2017 was conducted. IrH was defined as: (1) ACTH or TSH deficiency plus MRI changes or (2) ACTH and TSH deficiencies plus headache/fatigue in the absence of MRI findings. We found that of 83 patients followed for a median of 1.75 years (range 0.6-3), the proposed criteria used at initial evaluation accurately identified 61/62 (98%) irH cases. In the irH group (n = 62), the most common presentation was headache (60%), fatigue (66%), central hypothyroidism (94%), central adrenal insufficiency (69%) and MRI changes (77%). Compared with non-ipilimumab (ipi) regimens, ipi has a stronger association with irH occurrence (P = 0.004) and a shorter time to irH development (P < 0.01). Thyroid, gonadal and adrenal axis recovery occurred in 24, 58 and 0% patients, respectively. High-dose steroids (HDS) or ICI discontinuation was not associated with hormonal recovery. In the non-irH group (n = 19), one patient had isolated central hypothyroidism and six had isolated central adrenal insufficiency. All remained on hormone therapy at the last follow-up. We propose a strict definition of irH that identifies the vast majority of patients. HDS and ICI discontinuation is not always beneficial. Long-term follow-up to assess recovery is needed.
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Affiliation(s)
- Ha Nguyen
- Division of Internal Medicine, Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas Anderson Cancer Center, Houston, Texas, USA
| | - Komal Shah
- Division of Diagnostic Imaging, Department of Diagnostic Radiology, The University of Texas Anderson Cancer Center, Houston, Texas, USA
| | - Steven G Waguespack
- Division of Internal Medicine, Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas Anderson Cancer Center, Houston, Texas, USA
| | - Mimi I Hu
- Division of Internal Medicine, Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas Anderson Cancer Center, Houston, Texas, USA
| | - Mouhammed Amir Habra
- Division of Internal Medicine, Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas Anderson Cancer Center, Houston, Texas, USA
| | - Maria E Cabanillas
- Division of Internal Medicine, Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas Anderson Cancer Center, Houston, Texas, USA
| | - Naifa L Busaidy
- Division of Internal Medicine, Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas Anderson Cancer Center, Houston, Texas, USA
| | - Roland Bassett
- Division of Science, Department of Biostatistics, The University of Texas Anderson Cancer Center, Houston, Texas, USA
| | - Shouhao Zhou
- Division of Science, Department of Biostatistics, The University of Texas Anderson Cancer Center, Houston, Texas, USA
| | - Priyanka C Iyer
- Division of Internal Medicine, Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas Anderson Cancer Center, Houston, Texas, USA
| | - Garrett Simmons
- Division of Diagnostic Imaging, Department of Diagnostic Radiology, The University of Texas Anderson Cancer Center, Houston, Texas, USA
| | - Diana Kaya
- Division of Diagnostic Imaging, Department of Diagnostic Radiology, The University of Texas Anderson Cancer Center, Houston, Texas, USA
| | - Marie Pitteloud
- Division of Internal Medicine, Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas Anderson Cancer Center, Houston, Texas, USA
| | - Sumit K Subudhi
- Division of Cancer Medicine, Department of Genitourinary Medical Oncology, The University of Texas Anderson Cancer Center, Houston, Texas, USA
| | - Adi Diab
- Division of Cancer Medicine, Department of Melanoma Medical Oncology, The University of Texas Anderson Cancer Center, Houston, Texas, USA
| | - Ramona Dadu
- Division of Internal Medicine, Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas Anderson Cancer Center, Houston, Texas, USA
- Correspondence should be addressed to R Dadu;
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21
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Zhu J, Wang Z, Wang W, Fan J, Zhang Y, Li X, Liu J, Jiang S, Deng K, Duan L, Yao Y, Zhu H. Xanthomatous Hypophysitis: A Case Report and Comprehensive Literature Review. Front Endocrinol (Lausanne) 2021; 12:735655. [PMID: 34659121 PMCID: PMC8518622 DOI: 10.3389/fendo.2021.735655] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 09/15/2021] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Xanthomatous hypophysitis (XHP) is an extremely rare form of primary hypophysitis for which there is a lack of clinical experience. A comprehensive understanding of its clinical characteristics, diagnosis and treatment is needed. METHODS Here, we report a case study and conduct a systematic review of XHP. Thirty-six cases were included, and their clinical manifestations, endocrine assessment, imaging features, treatment and follow-up data were collected and analyzed. RESULTS The mean age at diagnosis was 39.1 years, and females were predominant (75.0%). The most common symptom was headache (68.6%), and 66.7% of female patients presented menstrual disorders. The most common pituitary dysfunction was growth hormone (GH) deficiency. More than half of patients exhibited central diabetes insipidus (CDI). The majority of patients had an imaging presentation of a cystic lesion with peripheral enhancement. Pituitary stalk thickening was observed in half of the patients. Total lesion resection was achieved in 57.1% of cases. The recurrence rate after partial resection and biopsy was significantly higher than that after total lesion resection (57.1% vs. 0.0%, P = 0.0147). The most common pituitary hormone abnormalities to resolve after surgery were hyperprolactinemia (100.0%) and GH deficiency (91.7%). The typical pathological feature was inflammatory infiltration of foamy histiocytes, which showed positivity for CD68. CONCLUSION Diagnosis of XHP is difficult when relying on clinical symptoms and imaging features. Therefore, surgical histopathology is necessary. Based on the available evidence, total lesion resection is recommended for treatment. However, the long-term prognosis for this rare disease remains unclear.
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Affiliation(s)
- Jianyu Zhu
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Zhicheng Wang
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Wenze Wang
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jinghua Fan
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yi Zhang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xiaoxu Li
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jie Liu
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Shenzhong Jiang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Kan Deng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Lian Duan
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yong Yao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- *Correspondence: Yong Yao, ; Huijuan Zhu,
| | - Huijuan Zhu
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- *Correspondence: Yong Yao, ; Huijuan Zhu,
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22
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Abstract
Once central diabetes insipidus (CDI) has been diagnosed, every effort should be made to reveal its underlying cause. Autoimmune CDI should be considered in the differential diagnosis of idiopathic CDI and also of mass lesions of the sella region. An autoimmune etiology of CDI was first suggested in 1983 by the detection of autoantibodies to hypothalamic vasopressin-producing cells (AVPcAb) in adults and also in children with the disease, using the indirect immunofluorescence test. The major autoantigen for autoimmune CDI has now been recognized as rabphilin-3A, a protein of secretory vesicles of the neurohypophyseal system. The detection of autoantibodies to rabphilin-3A by Western blotting or of AVPcAb provides strong evidence for the diagnosis of autoimmune CDI. Autoimmune CDI is recognized mostly in patients who had also been diagnosed with endocrine autoimmune disorders. The radiological and morphological correlate with autoimmune DI is lymphocytic infundibuloneurohypophysitis (LINH) as detected by magnetic resonance imaging and biopsies that show massive infiltration of the posterior pituitary and the infundibulum with lymphocytes and some plasma cells, and fibrosis in the later stages of the disease. LINH may be associated with lymphocytic anterior hypophysitis. Both may either appear spontaneously or on treatment with immune checkpoint inhibitors.
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Affiliation(s)
- Werner A Scherbaum
- Department of Endocrinology, Heinrich-Heine-University, Duesseldorf, Germany.
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23
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Gendreitzig P, Honegger J, Quinkler M. Granulomatous hypophysitis causing compression of the internal carotid arteries reversible with azathioprine and rituximab treatment. Pituitary 2020; 23:103-112. [PMID: 31748928 DOI: 10.1007/s11102-019-01005-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Compression of the internal carotid artery (ICA) in the cavernous sinus area is a rare event and is mostly associated with pituitary adenomas and meningiomas. Other causes of ICA compression are less well known. We present a rare case of granulomatous hypophysitis causing compression of the ICA, which was treated successfully with immune-suppressive agents. METHODS The electronic database MEDLINE (PubMed) was searched systematically and other cases with ICA compression were identified and analyzed. RESULTS A female patient with a history of two previous transsphenoidal operations for suspected pituitary adenoma and post-operative complete pituitary insufficiency presented with severe headaches, nausea, fatigue, and diplopia. Pituitary MRI scan suggested relapse of the pituitary lesion with atypical bilateral infiltration of cavernous sinuses and compression of ICAs. After histological reevaluation of her previous pituitary operations, granulomatous hypophysitis was diagnosed. Treatment was started with high doses of prednisolone. With decreasing doses of prednisolone, symptoms recurred, and azathioprine was started, followed by administration of rituximab resulting in clinical recovery and regression of ICA compression. Literature analysis disclosed 36 case reports with ICA compression in the cavernous sinus region (12 pituitary adenoma, 6 meningioma, 7 hypophysitis, 5 other tumors, and 4 other etiologies). Two cases of hypophysitis recovered completely; five cases improved only partly. CONCLUSION In the case of ICA compression, clinical signs, onset of symptoms, radiological findings and pituitary insufficiencies should be thoroughly evaluated, and hypophysitis should be considered as a possible cause. In our patient, treatment with azathioprine and, finally, rituximab was successful.
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Affiliation(s)
- Pauline Gendreitzig
- Endocrinology in Charlottenburg, Stuttgarter Platz 1, 10627, Berlin, Germany
| | - Jürgen Honegger
- Department for Neurosurgery, University Hospital Tübingen, 72076, Tübingen, Germany
| | - Marcus Quinkler
- Endocrinology in Charlottenburg, Stuttgarter Platz 1, 10627, Berlin, Germany.
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24
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Force BK, Vogel TP, Nguyen DM, Heck KA, Sebastian S, Takashima M, Yoshor D, Samson SL. A Remarkable Response of Granulomatous Hypophysitis to Infliximab in a Patient With a Background of Crohn's Disease-A Case Report. Front Endocrinol (Lausanne) 2020; 11:350. [PMID: 32547497 PMCID: PMC7272571 DOI: 10.3389/fendo.2020.00350] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 05/04/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Hypophysitis is primary or idiopathic or secondary to another disease process. The histologic subtypes of hypophysitis are lymphocytic, granulomatous, xanthomatous, xanthogranulomatous, or IgG4-related. Granulomatous hypophysitis is the second most common form and is characterized by multinucleated giant cells with granulomas and histiocytes. It can be idiopathic or secondary to another process such as infection, sarcoidosis, vasculitis, dendritic cell disorders, Crohn's disease (CD) or a reaction to rupture of a Rathke's cyst or pituitary adenoma. We present a case of granulomatous hypophysitis in a patient with CD who had resistance to corticosteroids but a dramatic response to immunosuppressive therapy with anti-tumor necrosis factor (TNF)-α therapy. Case description: A 43-year-old woman with a 9-year history of ileal and colonic CD presented to the Pituitary Center with headaches, visual disturbance, fatigue, nausea, and secondary amenorrhea. She was not on active therapy for her CD at the time of presentation and had no gastrointestinal symptoms. Hormonal evaluation revealed hyperprolactinemia, secondary hypothyroidism and adrenal insufficiency. MRI revealed a 12 × 12 × 19 mm sellar lesion abutting the optic chiasm, reported as a macroadenoma. The patient underwent endoscopic transsphenoidal biopsy of the pituitary mass. Pathology revealed granulomatous hypophysitis. Evaluation for secondary causes of hypophysitis, apart from CD, was negative. Despite a course of high dose prednisone, her symptoms and MRI findings worsened and she developed symptoms consistent with diabetes insipidus. Using a personalized medicine approach, she was started on anti-(TNF)-α therapy with infliximab combined with azathioprine, which are indicated for treatment of CD. Her headaches and polyuria resolved and her menstrual cycles resumed. MRI at 3 months and more than 1.5 years after initiation of anti-TNF-α therapy revealed durable resolution of the pituitary mass. Conclusion: To our knowledge, this is the first report of successful use of anti-TNF-α therapy for a patient with granulomatous hypophysitis, in this case associated with a previous diagnosis of CD. Although glucocorticoids are used frequently as first-line therapy for primary hypophysitis, granulomatous hypophysitis can be corticosteroid resistant and other immunosuppressive approaches may need to be considered within the context of the patient.
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Affiliation(s)
- Bahar K. Force
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, Baylor College of Medicine, Houston, TX, United States
- Baylor St. Luke's Pituitary Center, Houston, TX, United States
| | - Tiphanie P. Vogel
- Division of Rheumatology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| | - Dang M. Nguyen
- Greater Houston Gastroenterology, Houston, TX, United States
| | - Kent A. Heck
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, United States
| | - Sherly Sebastian
- Baylor St. Luke's Pituitary Center, Houston, TX, United States
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | - Mas Takashima
- Houston Methodist Hospital, Department of Otolaryngology, Houston, TX, United States
| | - Daniel Yoshor
- Baylor St. Luke's Pituitary Center, Houston, TX, United States
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | - Susan L. Samson
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, Baylor College of Medicine, Houston, TX, United States
- Baylor St. Luke's Pituitary Center, Houston, TX, United States
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
- *Correspondence: Susan L. Samson
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Pal R, Rai A, Vaiphei K, Gangadhar P, Gupta P, Mukherjee KK, Singh P, Ray N, Bhansali A, Dutta P. Intracranial Germinoma Masquerading as Secondary Granulomatous Hypophysitis: A Case Report and Review of Literature. Neuroendocrinology 2020; 110:422-429. [PMID: 31269501 DOI: 10.1159/000501886] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 07/02/2019] [Indexed: 12/22/2022]
Abstract
Germinomas are highly immunogenic tumors eliciting a strong peri-tumoral immune response that can spillover into the surrounding healthy tissues. This phenomenon can also occur in intracranial germinomas, manifesting as secondary hypophysitis. Herein, we report a case of 12-year-old-girl presenting with polyuria and polydispsia. She had central diabetes insipidus (CDI) and panhypopituitarism. Imaging revealed a sellar-suprasellar mass with infundibular stalk thickening. Transphenoidal biopsy revealed epithelioid granulomas with immunostaining negative for germinomatous cells. Other causes of hypophysitis were ruled out. Accordingly, she was diagnosed as primary granulomatous hypophysitis and treated with high-dose corticosteroids. Three years later she again presented with headache, vomiting and diminution of vision. Imaging showed a heterogeneous, solid-cystic peripheral rim-enhancing lesion at the same location with involvement of hypothalamus, ependyma and pineal gland. Cerebrospinal fluid beta-human chorionic gonadotropin was markedly elevated, confirming the diagnosis of an intracranial germ cell tumor. She was started on chemotherapy; however, she succumbed to febrile neutropenia. We performed a literature search and found 18 anecdotal cases of secondary hypophysitis associated with intracranial germinomas. There was a slight male preponderance (male:female 5:4). Two-thirds of the cases were below 18 years of age. Polyuria was the most common presenting manifestation (83%). CDI and panhypopituitarism were seen in 89 and 78% cases, respectively. Imaging evidence of pituitary stalk thickening was seen in 12 cases (67%), while pituitary enlargement and/or sellar mass were reported in 11 cases (61%). Pineal involvement was extremely rare, being reported in only 1 case, implying the predilection of suprasellar (rather than pineal) germinomas in causing secondary hypophysitis. Histologically, 82% had lymphocytic hypophysitis, while 18% had granulomatous hypophysitis. Initially, the diagnosis of germinoma was missed in 60% of the cases who were wrongly treated with corticosteroids. To conclude, physicians should make it a dictum that all children and adolescents presenting with CDI and pituitary stalk thickening should be rigorously screened for an underlying intracranial germinoma before labeling them as primary hypophysitis.
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Affiliation(s)
- Rimesh Pal
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashutosh Rai
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kim Vaiphei
- Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Prakamya Gupta
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kanchan Kumar Mukherjee
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Paramjeet Singh
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Nirmalya Ray
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Anil Bhansali
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Pinaki Dutta
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India,
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26
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Angelousi A, Alexandraki K, Tsoli M, Kaltsas G, Kassi E. Hypophysitis (Including IgG4 and Immunotherapy). Neuroendocrinology 2020; 110:822-835. [PMID: 32126548 DOI: 10.1159/000506903] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 03/02/2020] [Indexed: 11/19/2022]
Abstract
Hypophysitis is characterized by inflammation of the pituitary gland that can be primary (PH) or secondary (SH) to other diseases or following drug administration. It may also be classified according to anatomical and histopathological criteria, leading to variable degrees of hypopituitarism and/or compressive symptoms to nearby structures. There has recently been an increase in the number of hypophysitis cases, raising the interest on the spectrum of its pathogenesis, clinical, biochemical/endocrinological, and imaging features. However, the use of conventional biomarkers, including currently utilized pituitary autoantibodies, has relatively limited diagnostic accuracy. Lymphocytic hypophysitis (LH) is the commonest cause of PH, whereas IgG4-related hypophysitis is increasingly being recognized. Histiocytosis and granulomatous diseases are the most frequent causes of SH, although infections and lymphoma have also been reported. The increasing use of immune checkpoint inhibitors in oncology is associated with a high incidence of hypophysitis, providing further understanding of its pathogenesis. Hypophysitis can occur silently and be easily missed, potentially leading to substantial morbidity or mortality due to adrenal insufficiency, requiring a high index of clinical suspicion and timely initiation of appropriate treatment. In most cases of LH or drug-induced hypophysitis, active surveillance along with replacement of established hormonal deficiencies is needed. In the presence of compressive and/or evolving symptoms, treatment with glucocorticoids either alone or in combination with other immunosuppressive agents can be used. Surgical decompression is reserved for nonresponsive cases with threatened vital structures. Timely diagnosis and intervention are important to minimize disease-related morbidity and mortality. We aimed to review current concepts and recent developments in the pathogenesis, diagnosis, and management of hypophysitis.
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Affiliation(s)
- Anna Angelousi
- First Department of Internal Medicine, Laiko University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece,
| | - Krystallenia Alexandraki
- First Department of Propaedeutic Internal Medicine, Laiko University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Marina Tsoli
- First Department of Propaedeutic Internal Medicine, Laiko University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Gregory Kaltsas
- First Department of Propaedeutic Internal Medicine, Laiko University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Eva Kassi
- First Department of Propaedeutic Internal Medicine, Laiko University Hospital, National and Kapodistrian University of Athens, Athens, Greece
- Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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27
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Gubbi S, Hannah-Shmouni F, Verbalis JG, Koch CA. Hypophysitis: An update on the novel forms, diagnosis and management of disorders of pituitary inflammation. Best Pract Res Clin Endocrinol Metab 2019; 33:101371. [PMID: 31866206 PMCID: PMC7078033 DOI: 10.1016/j.beem.2019.101371] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Hypophysitis is a heterogeneous condition that leads to inflammation of the sella and/or suprasellar region, potentially resulting in hormonal deficiencies and/or mass effects. A preponderance of hypophysitis subtypes have an underlying autoimmune aetiology. The overall incidence and prevalence of hypophysitis has dramatically increased over the past decade, mainly due to increased awareness of the condition in the medical community, improvements in imaging techniques, and a rise in the occurrence of certain forms of hypophysitis such as IgG4 hypophysitis (IgG4Hy) and immune checkpoint inhibitor induced hypophysitis (ICIHy). The clinical presentation varies from an asymptomatic condition to a fatal disease often as a result of electrolyte abnormalities due to glucocorticoid deficiency in the context of adrenal crisis from central adrenal insufficiency. Milder forms of hypophysitis are treated with replacement of deficient hormones while more acute presentations with mass effects require glucocorticoid therapy, immunosuppressive therapy or surgery. Timely diagnosis and interventions are keys to prevention of the lethal complications of this disease. In this review, we provide an update on the recent advances in the field of pituitary autoimmunity, with an emphasis on autoimmune hypophysitis and novel forms of hypophysitis such as anti-PIT1 hypophysitis, IgG4Hy and ICIHy.
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Affiliation(s)
- Sriram Gubbi
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH), Bethesda, MD, 20892, USA.
| | - Fady Hannah-Shmouni
- Section on Endocrinology & Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, 20892, USA.
| | - Joseph G Verbalis
- Division of Endocrinology and Metabolism, Department of Medicine, Georgetown University Medical Center, Washington, DC, 20007, USA.
| | - Christian A Koch
- The University of Tennessee Health Science Center, Memphis, TN, 38163, USA; Fox Chase Cancer Center, Philadelphia, PA, USA.
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28
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Sharifi G, Mohajeri-Tehrani MR, Navabakhsh B, Larijani B, Valeh T. Idiopathic granulomatous hypophysitis presenting with galactorrhea, headache, and nausea in a woman: a case report and review of the literature. J Med Case Rep 2019; 13:334. [PMID: 31731892 PMCID: PMC6858767 DOI: 10.1186/s13256-019-2276-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 09/25/2019] [Indexed: 11/10/2022] Open
Abstract
Background Inflammation of the pituitary gland can occur in a variety of primary or secondary disorders. Idiopathic granulomatous hypophysitis is a rare inflammatory disease of the pituitary gland that can closely mimic a pituitary adenoma clinicoradiologically. Most authorities agree on minimally invasive transsphenoidal surgery as the mainstay in diagnosis and treatment of this disorder. There is still some controversy regarding pure medical management of idiopathic granulomatous hypophysitis in the literature. Case presentation A 47-year-old Iranian woman of Azeri ethnicity with a history of benign breast cysts with a chief complaint of galactorrhea presented to our endocrinology clinic. Her past medical history was negative for any menstrual irregularities, hirsutism, visual complaints, diplopia, polyuria and polydipsia or seizures. She was taking 100 mcg of levothyroxine daily. Her familial history and physical examination were unremarkable. Her initial laboratory work-up revealed hyperprolactinemia (82.4 ng/mL) with otherwise normal pituitary axes. Brain magnetic resonance imaging showed a pituitary macroadenoma for which she was treated with 0.5 mg of cabergoline weekly. Although her serum prolactin level dropped to 1.7 ng/mL and her galactorrhea was resolved, she continued to complain of headaches and nausea. Repeated imaging showed no decrease in size of the macroadenoma. Therefore, she underwent transsphenoidal surgery of the macroadenoma which was reported as chronic granulomatous hypophysitis by expert pathologists. Tuberculosis, sarcoidosis, Wegener’s granulomatosis, Langerhans cell histiocytosis, and syphilis were ruled out by appropriate tests and she was diagnosed as having idiopathic granulomatous hypophysitis. Fortunately, her condition was not complicated by hypopituitarism and she was symptom free 9 months after transsphenoidal surgery. Conclusions Idiopathic granulomatous hypophysitis, a rare inflammatory disease of the pituitary gland, is a diagnosis of exclusion for which both medical and surgical management are reported in the literature. We present a case of idiopathic granulomatous hypophysitis who was symptom free with no complications of hypopituitarism following its transsphenoidal resection after 9 months of follow-up.
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Affiliation(s)
- Guive Sharifi
- Department of Neurosurgery, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Mohajeri-Tehrani
- Endocrinology & Metabolism Research Center, Endocrinology & Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Dr. Shariati Hospital, Jalal Al Ahmad Highway, Tehran, 1411713137, Iran
| | - Behrouz Navabakhsh
- Endocrinology & Metabolism Research Center, Endocrinology & Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Dr. Shariati Hospital, Jalal Al Ahmad Highway, Tehran, 1411713137, Iran
| | - Bagher Larijani
- Endocrinology & Metabolism Research Center, Endocrinology & Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Dr. Shariati Hospital, Jalal Al Ahmad Highway, Tehran, 1411713137, Iran
| | - Touraj Valeh
- Endocrinology & Metabolism Research Center, Endocrinology & Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Dr. Shariati Hospital, Jalal Al Ahmad Highway, Tehran, 1411713137, Iran.
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29
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Romano A, Rigante D, Cipolla C. Autoimmune phenomena involving the pituitary gland in children: New developing data about diagnosis and treatment. Autoimmun Rev 2019; 18:102363. [PMID: 31401342 DOI: 10.1016/j.autrev.2019.102363] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 03/30/2019] [Indexed: 11/27/2022]
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30
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Chiloiro S, Capoluongo ED, Tartaglione T, Giampietro A, Bianchi A, Giustina A, Pontecorvi A, De Marinis L. The Changing Clinical Spectrum of Hypophysitis. Trends Endocrinol Metab 2019; 30:590-602. [PMID: 31345630 DOI: 10.1016/j.tem.2019.06.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 06/16/2019] [Accepted: 06/21/2019] [Indexed: 12/17/2022]
Abstract
Hypophysitis is a rare and potentially life-threatening disease, characterized by an elevated risk of complications, such as occurrence of acute central hypoadrenalism, persistent hypopituitarism, or extension of the inflammatory process to the neighboring neurological structures. In recent years, a large number of patients have been described as being affected by hypophysitis, due to the increased administration of immuno-chemotherapies. At the present time, the heterogeneous nature of hypophysitis diagnostic criteria and of the treatment protocols makes the management of affected patients difficult. We review the current data and evidence on primary and secondary hypophysitis, in order to suggest a diagnostic and therapeutic protocol that should be focused on a multidisciplinary approach, for reaching a prompt diagnosis and an appropriate and safe treatment.
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Affiliation(s)
- Sabrina Chiloiro
- Pituitary Unit, Department of Endocrinology, Fondazione A Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Tommaso Tartaglione
- Department of Radiology, Istituto Dermopatico dell'Immacolata, Rome and Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonella Giampietro
- Pituitary Unit, Department of Endocrinology, Fondazione A Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Bianchi
- Pituitary Unit, Department of Endocrinology, Fondazione A Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andrea Giustina
- Department of Endocrinology, Università Vita Salute San Raffaele, Milan, Italy
| | - Alfredo Pontecorvi
- Pituitary Unit, Department of Endocrinology, Fondazione A Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Laura De Marinis
- Pituitary Unit, Department of Endocrinology, Fondazione A Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.
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31
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Sivakoti S, Nandeesh BN, Bhatt AS, Chandramouli BA. Pituitary Adenoma with Granulomatous Hypophysitis: A Rare Coexistence. Indian J Endocrinol Metab 2019; 23:498-500. [PMID: 31741914 PMCID: PMC6844172 DOI: 10.4103/ijem.ijem_259_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Affiliation(s)
- Sumitra Sivakoti
- Department of Neuropathology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - B. N. Nandeesh
- Department of Neuropathology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Anusha S. Bhatt
- Department of Pathology, Kasturba Medical College, Mangalore, Karnataka, India
| | - B. A. Chandramouli
- Department of Neurosurgery, Aster RV Hospital, Bengaluru, Karnataka, India
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Wehbeh L, Alreddawi S, Salvatori R. Hypophysitis in the era of immune checkpoint inhibitors and immunoglobulin G4-related disease. Expert Rev Endocrinol Metab 2019; 14:167-178. [PMID: 30939947 DOI: 10.1080/17446651.2019.1598260] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 03/19/2019] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Hypophysitis is a rare disorder, defined as inflammation of the pituitary gland that may result in pituitary enlargement and varying anterior and posterior pituitary hormonal deficits. It involves different histopathological subtypes and variable etiologies, with considerable overlap between classification systems. Histopathology is the gold standard diagnostic approach. AREAS COVERED In this article, we will review the major histopathological subtypes of hypophysitis with a special focus on immunoglobulin G4 (IgG4)-related hypophysitis and immune checkpoint inhibitor-induced hypophysitis, given their recent appearance and increasing incidence. We will summarize the similarities and differences between the different subtypes as it relates to epidemiology, pathogenesis, presentation, diagnosis, and management. EXPERT OPINION Hypophysitis is a heterogeneous and wide term used to describe different, possibly distinct diseases often with poorly understood pathogenesis. It involves a wide range of subtypes with certain differences in incidence rates, pathogenesis, and management. Management usually focuses on relieving the mass effect symptoms and replacing the deficient pituitary hormones. Spontaneous recovery is possible but recurrence is not uncommon.
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Affiliation(s)
- Leen Wehbeh
- a Division of Endocrinology, Diabetes and Metabolism, and Pituitary Center , The Johns Hopkins University Hospital , Baltimore , MD , USA
| | - Sama Alreddawi
- b Medstar Health Internal Medicine Residency Program, Department of Medicine , Union Memorial Hospital , Baltimore , MD , USA
| | - Roberto Salvatori
- a Division of Endocrinology, Diabetes and Metabolism, and Pituitary Center , The Johns Hopkins University Hospital , Baltimore , MD , USA
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Park HJ, Park SH, Kim JH, Kim YH. Idiopathic Granulomatous Hypophysitis with Rapid Onset: A Case Report. Brain Tumor Res Treat 2019; 7:57-61. [PMID: 31062534 PMCID: PMC6504759 DOI: 10.14791/btrt.2019.7.e22] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Revised: 10/23/2018] [Accepted: 11/08/2018] [Indexed: 11/20/2022] Open
Abstract
Idiopathic granulomatous hypophysitis (IGH), a rare disease, requires differentiation from more common mass lesions of the sella such as pituitary adenoma, craniopharyngioma, Rathke's cleft cyst, or pituitary tuberculoma. IGH usually presents with an insidious onset of visual defects and headaches. On the other hand, rapid onset of neurologic and visual symptoms in an IGH patient is exceptionally rare. Here, we present a biopsy-proven case of IGH with rapid onset and satisfactory outcome after high dose steroid treatment.
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Affiliation(s)
- Hyun Joo Park
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sung Hye Park
- Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Hee Kim
- Pituitary Center, Seoul National University College of Medicine, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yong Hwy Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
- Pituitary Center, Seoul National University College of Medicine, Seoul, Korea.
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A Trial of Oral Glucocorticoids in the Resolution of Recurrent Granulomatous Hypophysitis: A Case Report. J ASEAN Fed Endocr Soc 2019; 34:210-214. [PMID: 33442158 PMCID: PMC7784091 DOI: 10.15605/jafes.034.02.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 06/20/2019] [Indexed: 11/20/2022] Open
Abstract
Granulomatous hypophysitis is an extremely rare condition, with no established definitive treatment. An elderly Asian woman was diagnosed to have recurrent granulomatous hypophysitis 5 years after transsphenoidal surgery. No other intervention was done post-operatively. Since another surgery was not advisable due to the high probability of recurrence, she was started on a trial of oral glucocorticoids. After 3 months of steroid therapy, complete resolution of symptoms and sellar mass were achieved.
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Joshi MN, Whitelaw BC, Carroll PV. MECHANISMS IN ENDOCRINOLOGY: Hypophysitis: diagnosis and treatment. Eur J Endocrinol 2018; 179:R151-R163. [PMID: 29880706 DOI: 10.1530/eje-17-0009] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 06/06/2018] [Indexed: 12/19/2022]
Abstract
Hypophysitis is a rare condition characterised by inflammation of the pituitary gland, usually resulting in hypopituitarism and pituitary enlargement. Pituitary inflammation can occur as a primary hypophysitis (most commonly lymphocytic, granulomatous or xanthomatous disease) or as secondary hypophysitis (as a result of systemic diseases, immunotherapy or alternative sella-based pathologies). Hypophysitis can be classified using anatomical, histopathological and aetiological criteria. Non-invasive diagnosis of hypophysitis remains elusive, and the use of currently available serum anti-pituitary antibodies are limited by low sensitivity and specificity. Newer serum markers such as anti-rabphilin 3A are yet to show consistent diagnostic value and are not yet commercially available. Traditionally considered a very rare condition, the recent recognition of IgG4-related disease and hypophysitis as a consequence of use of immune modulatory therapy has resulted in increased understanding of the pathophysiology of hypophysitis. Modern imaging techniques, histological classification and immune profiling are improving the accuracy of the diagnosis of the patient with hypophysitis. The objective of this review is to bring readers up-to-date with current understanding of conditions presenting as hypophysitis, focussing on recent advances and areas for future development. We describe the presenting features, investigation and diagnostic approach of the patient with likely hypophysitis, including existing conventional techniques and those in the research/development arena. Hypophysitis usually results in acute and persistent pituitary hormone deficiency requiring long-term replacement. Management of hypophysitis includes control of the inflammatory pituitary mass using a variety of treatment strategies including surgery and medical therapy. Glucocorticoids remain the mainstay of medical treatment but other immunosuppressive agents (e.g. azathioprine, rituximab) show benefit in some cases, but there is a need for controlled studies to inform practice.
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Affiliation(s)
- Mamta N Joshi
- Department of Endocrinology, Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - Benjamin C Whitelaw
- Department of Endocrinology, Kings College Hospital NHS Foundation Trust, London, UK
- Faculty of Life Sciences & Medicine, King's College Hospital London, London, UK
| | - Paul V Carroll
- Department of Endocrinology, Guy's & St. Thomas' NHS Foundation Trust, London, UK
- Faculty of Life Sciences & Medicine, King's College Hospital London, London, UK
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Tartaglione T, Chiloiro S, Laino ME, Giampietro A, Gaudino S, Zoli A, Bianchi A, Pontecorvi A, Colosimo C, De Marinis L. Neuro-radiological features can predict hypopituitarism in primary autoimmune hypophysitis. Pituitary 2018; 21:414-424. [PMID: 29752700 DOI: 10.1007/s11102-018-0892-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Primary autoimmune hypophysitis (PAH) is considered an underdiagnosed disease, due to the difficulty in reaching a definitive diagnosis. PAH clinical diagnosis remains an exclusion diagnosis. We aimed to correlate PAH neuro-radiological signs to endocrine features and evaluate their prognostic role. 24 PAH cases were enrolled and classified according to neuro-radiological signs: in 12 adeno-hypophysitis (AHs), 8 infundibulo-neuro-hypophysitis (INHs) and 4 pan-hypophysitis (PHs). Secondary hypogonadism developed more frequently in INHs as compared to AHs (54.5% vs. 27.3%, p = 0.05), without no difference with PHs (p = 0.6). Diabetes insipidus occurred more frequently in INHs cases (72.7%, p < 0.001) and in PHs cases (27.3%, p = 0.007), as compared to AHs cases (0%). Similarly, all cases of GHD occurred in INHs (100%) as compared to AHs (0%, p < 0.001) and PHs (0%, p < 0.001). The pituitary stalk (PS) showed a pseudo-triangular shape (larger at the optical chiasma) in INHs and a pseudo-cylindrical shape (larger both at the optical chiasma and at the pituitary insertion) in PHs. The PS pseudo-triangular shape correlated to the occurrence of GHD and diabetes insipidus (p < 0.001/p = 0.03). At the 1-year follow-up, improvement of baseline radiological features positively correlated with the loss of the neuro-pituitary "bright spot" on T1-weighted images (OR 0.16; 95% CI 0.03-0.9 p = 0.02) and with a PS diameter at the optical chiasma level larger than 4.1 mm (AUC 0.97, sensibility 80%, specificity 100%, OR 6; 95% CI1.1-28.8, p = 0.01) Our data suggest that neuro-radiological PAH classification in PH, AH and INH can predict pituitary dysfunction and that some neuro-radiological features, such as the pituitary stalk diameter and the loss of the neuro-pituitary bright spot on T1w images can play a role as a positive prognostic marker of the radiological hypophysitis outcome.
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Affiliation(s)
- Tommaso Tartaglione
- Institute of Radiology, School of Medicine, Catholic University of the Sacred Heart, Rome, Italy
| | - Sabrina Chiloiro
- Pituitary Unit, Department of Endocrinology, School of Medicine, Catholic University of the Sacred Heart, Rome, Italy
| | - Maria Elena Laino
- Institute of Radiology, School of Medicine, Catholic University of the Sacred Heart, Rome, Italy
| | - Antonella Giampietro
- Pituitary Unit, Department of Endocrinology, School of Medicine, Catholic University of the Sacred Heart, Rome, Italy
| | - Simona Gaudino
- Institute of Radiology, School of Medicine, Catholic University of the Sacred Heart, Rome, Italy
| | - Angelo Zoli
- Division of Rheumatology, Institute of Rheumatology and Affine Sciences, School of Medicine, Catholic University of the Sacred Heart, Rome, Italy
| | - Antonio Bianchi
- Pituitary Unit, Department of Endocrinology, School of Medicine, Catholic University of the Sacred Heart, Rome, Italy
| | - Alfredo Pontecorvi
- Pituitary Unit, Department of Endocrinology, School of Medicine, Catholic University of the Sacred Heart, Rome, Italy
| | - Cesare Colosimo
- Institute of Radiology, School of Medicine, Catholic University of the Sacred Heart, Rome, Italy
| | - Laura De Marinis
- Pituitary Unit, Department of Endocrinology, School of Medicine, Catholic University of the Sacred Heart, Rome, Italy.
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Agale SV, Binayke R, Kumari G, D'Costa GF. Idiopathic granulomatous hypophysitis: A report of an uncommon disorder. INDIAN J PATHOL MICR 2018; 61:389-392. [PMID: 30004061 DOI: 10.4103/ijpm.ijpm_77_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Hypophysitis of the pituitary gland is a rare inflammatory disorder and broadly classified as primary and secondary hypophysitis. Primary hypophysitis is mainly of lymphocytic, granulomatous, and xanthomatous types. Among the various primary hypophysitis, granulomatous hypophysitis is rare type with an incidence of 1 in 10 million. The various forms of hypophysitis are misdiagnosed as pituitary adenoma in 40% cases. Idiopathic granulomatous hypophysitis is even rarer inflammatory disorder accounting for <1% of cases involving panhypopituitarism with headache and visual disturbances. We report idiopathic granulomatous hypophysitis in a 28-year-old female presenting with blurring of vision and headache.
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Affiliation(s)
| | - Rachana Binayke
- Department of Pathology, Grant Govt. Medical College, Mumbai, Maharashtra, India
| | - Geeta Kumari
- Department of Pathology, Grant Govt. Medical College, Mumbai, Maharashtra, India
| | - Grace F D'Costa
- Department of Pathology, Grant Govt. Medical College, Mumbai, Maharashtra, India
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38
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Youssef A, Ali R, Marouf M. Granulomatous hypophysitis in a postpartum patient: A case report. COGENT MEDICINE 2018. [DOI: 10.1080/2331205x.2018.1428034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Alexey Youssef
- Faculty of Medicine, Tishreen University, MED Research Team, Lattakia, Syria
| | - Rahaf Ali
- Faculty of Medicine, Tishreen University, MED Research Team, Lattakia, Syria
| | - Maya Marouf
- Faculty of Medicine, Tishreen University, MED Research Team, Lattakia, Syria
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Elgamal ME, Mohamed RMH, Fiad T, Elgamal EA. Granulomatous hypophysitis: rare disease with challenging diagnosis. Clin Case Rep 2017; 5:1147-1151. [PMID: 28680614 PMCID: PMC5494403 DOI: 10.1002/ccr3.1007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 04/11/2017] [Indexed: 11/25/2022] Open
Abstract
Granulomatous hypophysitis is rare pathology that mimics pituitary adenoma. Diagnosis is only confirmed by histopathology examination. Trans‐sphenoidal surgery is considered diagnostic when descent tissue specimen is obtained and therapeutic by decompressing optic pathway and the sella. Pathological findings always reveal granulomatous areas, multinucleated giant cells, plasma cells, and lymphocytes.
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Affiliation(s)
- Mohannad E Elgamal
- College of Medicine Mohammed Bin Rashid University of Medicine and Health Sciences Dubai UAE
| | | | - Tarek Fiad
- Endocrinology Division Department of Medicine Sheikh Khalifa Medical City Abu Dhabi UAE
| | - Essam A Elgamal
- Neurosurgery Division Surgery Institute Sheikh Khalifa Medical City Abu Dhabi UAE
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40
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Clinical Interrogation for Unveiling an Isolated Hypophysitis Mimicking Pituitary Adenoma. World Neurosurg 2017; 99:735-744. [DOI: 10.1016/j.wneu.2016.07.071] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Revised: 07/18/2016] [Accepted: 07/19/2016] [Indexed: 01/29/2023]
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41
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Bernreuther C, Illies C, Flitsch J, Buchfelder M, Buslei R, Glatzel M, Saeger W. IgG4-related hypophysitis is highly prevalent among cases of histologically confirmed hypophysitis. Brain Pathol 2017; 27:839-845. [PMID: 27864854 DOI: 10.1111/bpa.12459] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 11/17/2016] [Indexed: 12/24/2022] Open
Abstract
IgG4-related disease is an immune-mediated disease with manifestations in most organ systems among them the pituitary gland. To date, few cases of histologically confirmed cases of IgG-related hypophysitis have been reported. The aim of this study was to retrospectively determine the prevalence of IgG4-related hypophysitis among cases previously diagnosed as primary hypophysitis (lymphocytic hypophysitis, granulomatous hypophysitis and hypophysitis not otherwise specified). Histological and immunohistochemical analysis revealed that 12 of 29 cases (41.4%) previously diagnosed as primary hypophysitis fulfilled the criteria for IgG4-related disease and, thus, IgG4-related hypophysitis should always be considered in the differential diagnosis of primary hypophysitis. All cases of IgG4-related hypophysitis showed a dense lymphoplasmacytic infiltrate with more than 10 IgG4-positive cells per high power field and a ratio of IgG4/IgG-positive cells of more than 40%, whereas storiform fibrosis was an inconsistent histological feature and was also seen in few cases of non-IgG-related hypophysitis, thus lacking sensitivity and specificity. Obliterative phlebitis was not seen in any case. Thus, histological criteria defined for IgG4-related disease in other organs should be modified for IgG4-related hypophysitis, accordingly.
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Affiliation(s)
- Christian Bernreuther
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christopher Illies
- Department of Pathology, Karolinska Institute and University Hospital, Stockholm, Sweden
| | - Jörg Flitsch
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Buchfelder
- Department of Neurosurgery, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Rolf Buslei
- Institute of Neuropathology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Markus Glatzel
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfgang Saeger
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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42
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Case 28. Neuroophthalmology 2017. [DOI: 10.1007/978-1-4471-2410-8_28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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43
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Rao S, Mahadevan A, Maiti T, Ranjan M, Shwetha SD, Arivazhagan A, Saini J. Granulomatous and lymphocytic hypophysitis - are they immunologically distinct? APMIS 2016; 124:1072-1077. [DOI: 10.1111/apm.12603] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Accepted: 08/09/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Shilpa Rao
- Department of Neuropathology; National Institute of Mental Health and Neurosciences; Bangalore India
| | - Anita Mahadevan
- Department of Neuropathology; National Institute of Mental Health and Neurosciences; Bangalore India
| | - Tanmoy Maiti
- Department of Neurosurgery; National Institute of Mental Health and Neurosciences; Bangalore India
| | - Manish Ranjan
- Department of Neurosurgery; National Institute of Mental Health and Neurosciences; Bangalore India
| | - Shivayogi Durgad Shwetha
- Human Brain Tissue Repository; National Institute of Mental Health and Neurosciences; Bangalore India
| | | | - Jitender Saini
- Neuroimaging and Intervention Radiology; National Institute of Mental Health and Neurosciences; Bangalore India
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Bilateral Carotid-Cavernous Fistulas: An Uncommon Cause of Pituitary Enlargement and Hypopituitarism. Case Rep Endocrinol 2016; 2016:6364203. [PMID: 27651959 PMCID: PMC5019923 DOI: 10.1155/2016/6364203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 08/07/2016] [Indexed: 11/22/2022] Open
Abstract
Carotid-cavernous fistulas (CCFs) are rare, pathologic communications of the carotid artery and the venous plexus of the cavernous sinus. They can develop spontaneously in certain at risk individuals or following traumatic head injury. Typical clinical manifestations include headache, proptosis, orbital pain, and diplopia. We report a case of bilateral carotid-cavernous fistulas associated with these symptoms and also with pituitary enlargement and hypopituitarism, which improved following surgical intervention. Arterialization of the cavernous sinus and elevated portal pressure may interfere with normal venous drainage and the conveyance of inhibiting and releasing hormones from the hypothalamus, resulting in pituitary enlargement and hypopituitarism. This condition should be considered in the differential diagnosis of hypopituitarism associated with anterior pituitary enlargement.
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45
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Wan Muhamad Hatta SF, Hamdan MF, Md Ali SA, Abdul Ghani R. Granulomatous hypophysitis: a case of severe headache. BMJ Case Rep 2016; 2016:bcr-2016-216395. [PMID: 27613264 DOI: 10.1136/bcr-2016-216395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Idiopathic granulomatous hypophysitis (GH) is an uncommon inflammatory disease of the pituitary with impairment of pituitary gland function due to infiltration by lymphocytes, plasma cells and macrophages. We report the case of a 39-year-old woman who presented with worsening of headaches for 1 month and blurring of vision over 5 days. An MRI revealed a homogeneous supra-sellar mass evoking a pituitary tumour with bulky pituitary stalk extending into the left and right cavernous sinuses. Hormonal investigations showed anterior pituitary hormone deficiencies; meanwhile histopathological examination revealed an aspect of hypophysitis. Clinical and radiological remission occurred immediately postglucocorticoid therapy with the addition of a steroid-sparing agent later in view of recurrence of symptoms on glucocorticoid dose reduction. GH has important diagnostic and therapeutic implications, as clinical and radiological features ameliorate via medical treatment. With further understanding and recognition of the disease, we hope to highlight a case of GH, in which signs and symptoms improved after initiation of corticosteroids.
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Affiliation(s)
| | - M Farhan Hamdan
- Department of Radiology, Faculty of Medicine, Universiti Teknologi MARA, Selangor, Sungai Buloh, Malaysia
| | - Siti Aishah Md Ali
- Department of Anatomy & Pathology, Faculty of Medicine, Universiti Teknologi MARA, Selangor, Malaysia
| | - Rohana Abdul Ghani
- Endocrine Unit, Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia
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Abstract
Hypophysitis is the acute or chronic inflammation of the pituitary gland. The spectrum of hypophysitis has expanded in recent years with the addition of two histologic subtypes and recognition as a complication of treatment with immune checkpoint inhibitors. Despite the increased number of published cases, the pathogenesis of hypophysitis is poorly understood, and treatment strategies are diverse and controversial. The diagnosis of hypophysitis generally requires histopathologic confirmation. The presentation and clinical course of hypophysitis varies. Hypophysitis can resolve spontaneously, relapse may occur, and some cases can be refractory to treatment.
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Affiliation(s)
- Alexander Faje
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114 USA
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47
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Postpartum Granulomatous Hypophysitis: A Case Study, Review of the Literature, and Discussion of Pathogenesis. Case Rep Pathol 2016; 2016:7510323. [PMID: 27642532 PMCID: PMC5013220 DOI: 10.1155/2016/7510323] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 07/31/2016] [Indexed: 11/17/2022] Open
Abstract
Hypophysitis is a rare inflammatory condition of the pituitary gland that has three main histologic subtypes: lymphocytic hypophysitis (LH), granulomatous hypophysitis (GH), and xanthomatous hypophysitis (XH). Among these, LH is the most common and is strongly associated with the postpartum state, while XH is the least common. Many hypophysitis cases have been reported in the literature but only a few cases of postpartum GH have been discussed. Here, we describe a case of GH in a 24-year-old female presenting eleven days postpartum. We also review the current literature on postpartum GH and discuss the possible alterations in the immune environment during and after pregnancy that could explain this phenomenon. With more cases of GH being reported, the commonalities of female predominance, postpartum time of presentation, and occasional spontaneous resolution between LH and GH lend support to the theory that these two diseases likely represent spectrums of a single immunologic disorder.
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48
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Huang M, Steele WJ, Baskin DS. Primary central nervous system vasculitis preceded by granulomatous hypophysitis: Case report with a review of the literature. Surg Neurol Int 2015; 6:S407-13. [PMID: 26539311 PMCID: PMC4597298 DOI: 10.4103/2152-7806.166176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 06/29/2015] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Primary central nervous system (CNS) vasculitis is an idiopathic inflammatory process that selectively affects CNS vasculature without a systemic inflammatory response, and causes luminal obstruction with resultant ischemia of recipient tissue. Its varying clinical symptoms and signs depend on the caliber of vessels involved and distribution and location of the affected structures. Granulomatous hypophysitis (GH) is an autoimmune inflammatory process typically affecting women, and usually presents with hypopituitarism, and at times, diabetes insipidus, and/or visual loss. Both entities are rare CNS diseases, which, to our knowledge, have never been previously reported in the same patient. CASE DESCRIPTION We present a unique case of chronic progressive primary CNS vasculitis causing limbic encephalopathy in a 30-year-old male with only a history of medication-controlled hypertension. He initially presented 4 months prior with nonspecific neurological complaints and was found to have a homogenously enhancing and enlarged pituitary, which was biopsy proven to be GH. CONCLUSION This rather unique presentation highlights the need to maintain a high index of suspicion for underlying PCNS vasculitis in a patient who does not fit the typical demographic for isolated GH.
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Affiliation(s)
- Meng Huang
- Department of Neurosurgery, Kenneth R. Peak Brain and Pituitary Center, Houston Methodist Neurological Institute, Houston, TX, USA
| | - William J Steele
- Department of Neurosurgery, Kenneth R. Peak Brain and Pituitary Center, Houston Methodist Neurological Institute, Houston, TX, USA
| | - David S Baskin
- Department of Neurosurgery, Kenneth R. Peak Brain and Pituitary Center, Houston Methodist Neurological Institute, Houston, TX, USA
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49
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Honegger J, Schlaffer S, Menzel C, Droste M, Werner S, Elbelt U, Strasburger C, Störmann S, Küppers A, Streetz-van der Werf C, Deutschbein T, Stieg M, Rotermund R, Milian M, Petersenn S. Diagnosis of Primary Hypophysitis in Germany. J Clin Endocrinol Metab 2015; 100:3841-9. [PMID: 26262437 DOI: 10.1210/jc.2015-2152] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
CONTEXT Representative data on diagnostic findings in primary hypophysitis (PrHy) are scarce. OBJECTIVE The objective of the study was to collate consistent data on clinical features in a large series of patients with PrHy. Another objective was to gain information on current practice in a diagnostic work-up. DESIGN The Pituitary Working Group of the German Society of Endocrinology conducted a nationwide retrospective cross-sectional cohort study in Germany. PATIENTS Seventy-six patients with PrHy were identified. MAIN OUTCOME MEASURES Clinical and endocrinological features were assessed. RESULTS Headache (50%) and increase in body mass (18%) were the most frequent nonendocrine symptoms. Hypophysitis was associated with pregnancy in only 11% of the female patients. Diabetes insipidus was found in 54% of the patients at presentation. Hypogonadotropic hypogonadism was the most frequent endocrine failure (62%), whereas GH deficiency was the least frequent (37%). With 86%, thickening of the pituitary stalk was the prevailing neuroradiological sign. Compared with surgical cases, the cases without histological confirmation presented more often with suprasellar lesions and had less severe nonendocrine symptoms. Granulomatous hypophysitis was associated with more severe clinical symptoms than lymphocytic hypophysitis. Examination of cerebrospinal fluid was predominantly performed in participating neurosurgical centers, whereas thyroid antibodies were almost exclusively assessed in endocrinological centers. CONCLUSION In contrast to the literature, hypogonadism was found to be the most frequent endocrine failure in PrHy. Weight gain was identified as a clinical sign of PrHy. In the majority of patients, PrHy can be reliably identified by characteristic clinical signs and symptoms, obviating histological confirmation. The diagnostic approach should be standardized in PrHy.
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Affiliation(s)
- Jürgen Honegger
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Sven Schlaffer
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Christa Menzel
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Michael Droste
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Sandy Werner
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Ulf Elbelt
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Christian Strasburger
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Sylvère Störmann
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Anna Küppers
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Christine Streetz-van der Werf
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Timo Deutschbein
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Mareike Stieg
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Roman Rotermund
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Monika Milian
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Stephan Petersenn
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
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Kong X, Wang R, Yang Y, Wu H, Su C, Ma W, Li Y, Xing B, Lian W, Xu Z, Yao Y, Ren Z. Idiopathic Granulomatous Hypophysitis Mimicking Pituitary Abscess. Medicine (Baltimore) 2015; 94:e1099. [PMID: 26181544 PMCID: PMC4617072 DOI: 10.1097/md.0000000000001099] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Idiopathic granulomatous hypophysitis (IGH) is a rare inflammatory disease of the pituitary that commonly presents with enlargement of the pituitary gland. Clinically and radiologically, IGH is a rare sellar entity easily to be misdiagnosed as a pituitary adenoma. Through such a case, we aim to present this rarity and emphasize the importance to correctly diagnose confusing pituitary lesions comprehensively by clinical presentations, radiological signs, and biopsy. We present an uncommon case of IGH in a 19-year-old man. The patient was admitted to the hospital with severe headache, vomiting, and vision's sharp decline. Magnetic resonance imaging showed a sellar lesion with obvious cystic change and ring enhancement. The disease course including diagnosis and treatment was presented and analyzed in detail. The pertinent literature is reviewed regarding this uncommon entity. The patient underwent surgical exploration and partial resection via the transsphenoidal approach. The pathologic findings suggested IGH giving no significant evidences of systemic granulomatous disease and venereal disease. Large dose methylprednisolone was then used. The pituitary function recovered, but there was no apparent improvement of his vision. IGH is a rarely occurred inflammatory disease of unknown etiology. It is difficult to diagnose preoperatively and is often misdiagnosed. Although rare, IGH should be kept in mind in terms of differential diagnosis of sellar region lesions.
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Affiliation(s)
- Xiangyi Kong
- From the Department of Neurosurgery (XK, RW, YY, CS, WM, YL, BX, WL, ZX, YY, ZR), Peking Union Medical College Hospital, Chinese Academy of Medical Sciences; and Department of Pathology (HW), Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, No. 1 Shuaifuyuan Hutong of Dongcheng District, Beijing, P. R. China
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